553148 research-article2015
SJS0010.1177/1457496914553148LRYGB vs LAGB in super-obese patients (BMI >50)S. Giordano, et al.
Original Article
Scandinavian Journal of Surgery 104: 5–9, 2015
Laparoscopic Roux-En-Y Gastric Bypass Versus Laparoscopic Adjustable Gastric Banding in the Super-Obese: Peri-Operative and Early Outcomes S. Giordano1,2, P. Tolonen2, M. Victorzon2 1 Department 2 Department
of Plastic and General Surgery, Turku University Hospital, Turku, Finland of Gastrointestinal Surgery, Vaasa Central Hospital, Vaasa, Finland
Abstract
Introduction: Controversy exists between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding in super-obese patients. Methods: This is a retrospective review of prospectively collected data. A total of 102 consecutive super-obese (body mass index >50) patients underwent laparoscopic Rouxen-Y gastric bypass (Group 1), and 79 consecutive ones underwent laparoscopic adjustable gastric banding (Group 2). Early complications and weight loss outcomes were evaluated. Results: No significant difference was found in operative mean (±standard deviation) time (93.5 ± 33 vs 87.7 ± 39 min, p = 0.29), hospital stay (2.68 ± 2.27 vs 2.75 ± 1.84 days, p = 0.80), or overall early postoperative morbidity (17.65% and 10.12%, p = 0.20). Intra-operative complications occurred in six patients (5.9%) in Group 1 and none in Group 2 (0.0%, p = 0.04). Mean excess weight loss percent at 6 and 12 months in Group 1 was 44.75% ± 11.84% and 54.71% ± 18.18% versus 26.20% ± 12.42% and 31.55% ± 19.79% in Group 2 (p 50 Introduction Bariatric surgery has proven effective in reducing weight, decreasing comorbidities and mortality, and
Correspondence: Salvatore Giordano, M.D. Department of Plastic and General Surgery Turku University Hospital OS 299, PL 52 20521 Turku Finland Email: [email protected]; salvatore. [email protected]
improving quality of life of morbidly obese patients (1–3). Morbid obesity is defined as a body mass index (BMI) >40 or >35 kg/m2 with comorbidities, while patients with BMI >50 kg/m2 are classified as superobese (4). Many operations have been proposed, but only a few are currently in use. Despite the marked increase in prevalence of sleeve gastrectomy worldwide (27.8%) in 2011, laparoscopic Roux-en-Y gastric bypass (LRYGB; 46.6%) and laparoscopic adjustable gastric banding (LAGB; 17.8%) are still very common procedures (5, 6). While LRYGB seems to be advantageous in terms of weight loss (WL), LAGB could be more suited for high-risk patients because of its lesser invasiveness and complication rate in the short term (6). Controversy still exists regarding the indications and
6
S. Giordano, et al. Table 1 Demographics of patients at time of study.
Agea Sex ratio (F:M) Weighta (kg) BMIa (kg/m²) Excess weighta (kg) Excess weighta (%)
Group 1 (n = 102)
Group 2 (n = 79)
p value
42.6 ± 11.43 65:37 165.6 ± 27.7 56.3 ± 6.9 92.0 ± 23.4 125.0 ± 27.6
41.0 ± 9.61 51:28 159.0 ± 21.0 53.4 ± 3.8 84.6 ± 14.7 113.8 ± 15.3
0.81 0.94 0.31 0.56 0.37 0.42
SD: standard deviation; BMI: body mass index. aValues are expressed as mean ± SD.
outcomes of these two operations. For super-obese patients, the picture is even less clear, and successful treatment of super-obese patients has been reported following both LRYGB and LAGB. There is progressive health impairment with increasing BMI (7). Therefore, super-obese patients have a higher incidence of medical comorbidity such as hypertension, diabetes mellitus, pulmonary dysfunction, sleep apnea, and degenerative arthritis, predisposing these patients to a greater risk following bariatric surgery (8). Further complicating this issue is the lack of evidence-based outcome data comparing LRYGB and LAGB in this high-risk patient population. The literature regarding both LAGB and LRYGB in super-morbidly obese patients is sparse. Many studies combine data of all patients who meet criteria for bariatric surgery, despite differences in comorbidity, technical considerations, and outcome associated with more advanced stages of obesity. The aim of this study is to compare the early outcomes and peri-operative complications of LRYGB and LAGB operations in superobese patients. Methods This is a retrospective review of prospectively collected data. Between 2006 and 2009, 733 consecutive patients underwent laparoscopic bariatric surgery at our institution (a district hospital), operated by the same surgical team (297 LAGB and 436 LRYGB). Of these patients, 181 (24.69%) had a BMI >50 kg/m2 and were classified as super-obese. Inclusion criteria for this study were as follows: BMI >50 kg/m2, a minimum follow-up of 12 months, and no previous bariatric procedures (revisional surgery excluded). Patients were divided into two groups on the basis of the procedure. Patient characteristics are outlined in Table 1. Correspondingly, 91.1% and 74.7% suffered from at least one of the most typical co-morbid conditions associated with heavy overweight. Operative time, intra-operative complications, hospital stay, and major and minor complications were compared. Complications were defined and graded according to Clavien–Dindo classification (9). Patients were followed every 3 months for the first year, through our institutional bariatric surgery outpatient clinic. Data were entered prospectively into
the hospital’s database for bariatric patients and retrospectively reviewed. WL, BMI, and excess weight loss percent (EWL%) outcomes were evaluated at 6 and 12 months postoperatively. The study protocol was approved by the Institutional Review Board. Operative Technique and Peri-Operative Management
The surgical technique used for LAGB has been previously described (10). Basically, we used the “pars flaccida” technique and a broad, low-pressure band, the Swedish adjustable gastric band (Obtech, Baar, Switzerland, later and now associated with Ethicon Endo-Surgery, Cincinnati, Ohio, United States). LRYGB was performed using a 5-trocar, double-loop technique and treated by fast-track pathways as recently described in detail (11). Fast-track compliance was 100%. In total, 11 super-obese patients were operated by the means of circular stapler in the creation of the gastrojejunal anastomosis as also described earlier because it was our standard technique during the first 30 LRYGB cases (12). Statistical Analysis
The results of parametric and nonparametric data were expressed as mean ± standard deviation (SD), and SPSS statistical software (SPSS 16.0.1, Chicago, IL, USA) was used for all statistical analyses. Confidence intervals were set at 95%. A two-sided p value of ≤0.05 was considered as statistically significant. Comparisons between both groups were determined using Fisher’s exact test for discrete variables because of the nonparametric nature of the data and Student’s t-test for continuous variables. A post hoc statistical power of 0.184 was calculated for the two-tailed hypothesis for the continuous outcome measures, while a post hoc statistical power of 0.292 for discrete variables with an observed effect size (Cohen’s d) of 0.159. Results The two groups were comparable (Table 1). There were no significant differences in operative time (93.51 ± 33.32 vs 87.72 ± 39.24 min), conversion rates (0% in both groups), or hospital stay (2.68 ± 2.27 vs 2.75 ± 1.84). A total of six patients (5.9%) in Group 1 had intra-operative complications due to anastomotic or gastric pouch leak during intra-operative leak testing with methylene blue (three patients), bowel perforations due to stapler—iatrogenic injury—(two patients), and one case of anvil detachment from gastric tube in the upper esophagus because a circular stapling gastrojejunal anastomosis was performed that needed intra-operative gastroscopy. However, all intra-operative complications were managed without further sequel. No intra-operative complications occurred in Group 2 (0.0%), with a significant difference (p = 0.04). There were no significant differences in overall early postoperative complication rates between the groups, although the LRYGB group had a higher early morbidity rate (17.65% vs 10.12%, p = 0.20) compared to the
7
LRYGB vs LAGB in super-obese patients (BMI >50) Table 2 Postoperative complications 50)
Declaration of Conflicting Interests No commercial associations or disclosures may pose or create any conflict of interest with the information presented in this article.
References 1. Sjöström L: Review of the key results from the Swedish Obese Subjects (SOS) trial—A prospective controlled intervention study of bariatric surgery. J Intern Med 2013;273:219–234. 2. Helmiö M, Salminen P, Sintonen H et al: A 5-year prospective quality of life analysis following laparoscopic adjustable gastric banding for morbid obesity. Obes Surg 2011;21:1585–1591. 3. Sarwer DB, Wadden TA, Moore RH et al: Changes in quality of life and body image after gastric bypass surgery. Surg Obes Relat Dis 2010;6:608–614. 4. Fielding GA. Laparoscopic adjustable gastric banding for massive superobesity (>60 body mass index kg/m2). Surg Endosc 2003;17:1541–1545. 5. Buchwald H, Oien DM: Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–436. 6. Chakravarty PD, McLaughlin E, Whittaker D et al: Comparison of laparoscopic adjustable gastric banding (LAGB) with other bariatric procedures: A systematic review of the randomised controlled trials. Surgeon 2012;10:172–182. 7. Flegal KM, Kit BK, Orpana H et al: Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA 2013;309:71–82. 8. Kyrou I, Osei-Assibey G, Williams N et al: Self-reported disability in adults with severe obesity. J Obes 2011;2011:918402. 9. Dindo D, Demartines N, Clavien PA: Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240: 205–213. 10. Victorzon M, Tolonen P: Laparoscopic silicone adjustable gastric band: Initial experience in Finland. Obes Surg 2000;10: 369–371. 11. Victorzon M, Victorzon S, Peromaa-Haavisto P: Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature. Obes Surg 2013;23:1692–1967. 12. Giordano S, Tolonen P, Victorzon M: Comparison of linear versus circular stapling techniques in laparoscopic gastric bypass surgery—A pilot study. Scand J Surg 2010;99:127–131. 13. Schwartz ML, Drew RL, Chazin-Caldie M: Factors determining conversion from laparoscopic to open Roux-en-Y gastric bypass. Obes Surg 2004;14:1193–1197. 14. Victorzon M: Revisional bariatric surgery by conversion to gastric bypass or sleeve—Good short-term outcomes at higher risks. Obes Surg 2012;22:29–33. 15. Topart P, Becouarn G, Ritz P: Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Rouxen-Y gastric bypass in superobese patients. Surg Obes Relat Dis 2013;9:526–530. 16. DeMaria EJ, Schauer P, Patterson E et al: The optimal surgical management of the super-obese patient: The debate. Paper presented at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Hollywood, FL, 13–16 April; Surg Innov 2005;12:107–121.
9
17. Christou NV, Look D, MacLean LD: Weight gain after shortand long-limb gastric bypass in patients followed for longer than 10 years. Ann Surg 2006;244:734–740. 18. Søvik TT, Taha O, Aasheim ET et al: Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Br J Surg 2010;97:160–166. 19. Suter M, Calmes JM, Paroz A et al: Results of Roux-en-Y gastric bypass in morbidly obese vs superobese patients: Similar body weight loss, correction of comorbidities, and improvement of quality of life. Arch Surg 2009;144:312–318. 20. Parikh MS, Shen R, Weiner M et al: Laparoscopic bariatric surgery in super-obese patients (BMI >50) is safe and effective: A review of 332 patients. Obes Surg 2005;15:858–863. 21. Kakarla VR, Nandipati K, Lalla M et al: Are laparoscopic bariatric procedures safe in superobese (BMI ≥50 kg/m2) patients? An NSQIP data analysis. Surg Obes Relat Dis 2011;7:452–458. 22. Favretti F, Ashton D, Busetto L et al: The gastric band: First-choice procedure for obesity surgery. World J Surg 2009;33:2039–2048. 23. Benotti P, Wood GC, Winegar DA et al: Risk factors associated with mortality after Roux-en-Y gastric bypass surgery. Ann Surg 2014;259:123–130. 24. Victorzon M, Peromaa-Haavisto P, Tolonen P: Perioperative morbidity, mortality and early outcome of the first 360 gastric bypass operations performed in a district hospital. Scand J Surg 2012;101:184–189. 25. Nguyen NT, Slone JA, Nguyen XM et al: A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: Outcomes, quality of life, and costs. Ann Surg 2009;250:631–641. 26. Angrisani L, Cutolo PP, Formisano G et al: Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 10-year results of a prospective, randomized trial. Surg Obes Relat Dis 2013;9:405–413. 27. Arapis K, Chosidow D, Lehmann M et al: Long-term results of adjustable gastric banding in a cohort of 186 super-obese patients with a BMI ≥50 kg/m2. J Visc Surg 2012;149:e143–e152. 28. O’Brien PE, MacDonald L, Anderson M et al: Long-term outcomes after bariatric surgery: Fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2013;257:87–94. 29. Werling M, Fändriks L, Björklund P et al: Long-term results of a randomized clinical trial comparing Roux-en-Y gastric bypass with vertical banded gastroplasty. Br J Surg 2013;100:222–230. 30. Neff KJ, Chuah LL, Aasheim ET et al: Beyond weight loss: Evaluating the multiple benefits of bariatric surgery after Rouxen-Y gastric bypass and adjustable gastric band. Obes Surg 2014;24:684–691. 31. Mognol P, Chosidow D, Marmuse JP: Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: A comparative study of 290 patients. Obes Surg 2005;15:76–81. 32. Bowne WB, Julliard K, Castro AE et al: Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: A prospective, comparative analysis. Arch Surg 2006;141:683–689. 33. Vidal P, Ramón JM, Goday A et al: Lack of adherence to followup visits after bariatric surgery: Reasons and outcome. Obes Surg 2014;24:179–183.
Received: April 15, 2014 Accepted: September 1, 2014
SJS0010.1177/1457496914553148LRYGB vs LAGB in super-obese patients (BMI >50)S. Giordano, et al.
Original Article
Scandinavian Journal of Surgery 104: 5–9, 2015
Laparoscopic Roux-En-Y Gastric Bypass Versus Laparoscopic Adjustable Gastric Banding in the Super-Obese: Peri-Operative and Early Outcomes S. Giordano1,2, P. Tolonen2, M. Victorzon2 1 Department 2 Department
of Plastic and General Surgery, Turku University Hospital, Turku, Finland of Gastrointestinal Surgery, Vaasa Central Hospital, Vaasa, Finland
Abstract
Introduction: Controversy exists between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding in super-obese patients. Methods: This is a retrospective review of prospectively collected data. A total of 102 consecutive super-obese (body mass index >50) patients underwent laparoscopic Rouxen-Y gastric bypass (Group 1), and 79 consecutive ones underwent laparoscopic adjustable gastric banding (Group 2). Early complications and weight loss outcomes were evaluated. Results: No significant difference was found in operative mean (±standard deviation) time (93.5 ± 33 vs 87.7 ± 39 min, p = 0.29), hospital stay (2.68 ± 2.27 vs 2.75 ± 1.84 days, p = 0.80), or overall early postoperative morbidity (17.65% and 10.12%, p = 0.20). Intra-operative complications occurred in six patients (5.9%) in Group 1 and none in Group 2 (0.0%, p = 0.04). Mean excess weight loss percent at 6 and 12 months in Group 1 was 44.75% ± 11.84% and 54.71% ± 18.18% versus 26.20% ± 12.42% and 31.55% ± 19.79% in Group 2 (p 50 Introduction Bariatric surgery has proven effective in reducing weight, decreasing comorbidities and mortality, and
Correspondence: Salvatore Giordano, M.D. Department of Plastic and General Surgery Turku University Hospital OS 299, PL 52 20521 Turku Finland Email: [email protected]; salvatore. [email protected]
improving quality of life of morbidly obese patients (1–3). Morbid obesity is defined as a body mass index (BMI) >40 or >35 kg/m2 with comorbidities, while patients with BMI >50 kg/m2 are classified as superobese (4). Many operations have been proposed, but only a few are currently in use. Despite the marked increase in prevalence of sleeve gastrectomy worldwide (27.8%) in 2011, laparoscopic Roux-en-Y gastric bypass (LRYGB; 46.6%) and laparoscopic adjustable gastric banding (LAGB; 17.8%) are still very common procedures (5, 6). While LRYGB seems to be advantageous in terms of weight loss (WL), LAGB could be more suited for high-risk patients because of its lesser invasiveness and complication rate in the short term (6). Controversy still exists regarding the indications and
6
S. Giordano, et al. Table 1 Demographics of patients at time of study.
Agea Sex ratio (F:M) Weighta (kg) BMIa (kg/m²) Excess weighta (kg) Excess weighta (%)
Group 1 (n = 102)
Group 2 (n = 79)
p value
42.6 ± 11.43 65:37 165.6 ± 27.7 56.3 ± 6.9 92.0 ± 23.4 125.0 ± 27.6
41.0 ± 9.61 51:28 159.0 ± 21.0 53.4 ± 3.8 84.6 ± 14.7 113.8 ± 15.3
0.81 0.94 0.31 0.56 0.37 0.42
SD: standard deviation; BMI: body mass index. aValues are expressed as mean ± SD.
outcomes of these two operations. For super-obese patients, the picture is even less clear, and successful treatment of super-obese patients has been reported following both LRYGB and LAGB. There is progressive health impairment with increasing BMI (7). Therefore, super-obese patients have a higher incidence of medical comorbidity such as hypertension, diabetes mellitus, pulmonary dysfunction, sleep apnea, and degenerative arthritis, predisposing these patients to a greater risk following bariatric surgery (8). Further complicating this issue is the lack of evidence-based outcome data comparing LRYGB and LAGB in this high-risk patient population. The literature regarding both LAGB and LRYGB in super-morbidly obese patients is sparse. Many studies combine data of all patients who meet criteria for bariatric surgery, despite differences in comorbidity, technical considerations, and outcome associated with more advanced stages of obesity. The aim of this study is to compare the early outcomes and peri-operative complications of LRYGB and LAGB operations in superobese patients. Methods This is a retrospective review of prospectively collected data. Between 2006 and 2009, 733 consecutive patients underwent laparoscopic bariatric surgery at our institution (a district hospital), operated by the same surgical team (297 LAGB and 436 LRYGB). Of these patients, 181 (24.69%) had a BMI >50 kg/m2 and were classified as super-obese. Inclusion criteria for this study were as follows: BMI >50 kg/m2, a minimum follow-up of 12 months, and no previous bariatric procedures (revisional surgery excluded). Patients were divided into two groups on the basis of the procedure. Patient characteristics are outlined in Table 1. Correspondingly, 91.1% and 74.7% suffered from at least one of the most typical co-morbid conditions associated with heavy overweight. Operative time, intra-operative complications, hospital stay, and major and minor complications were compared. Complications were defined and graded according to Clavien–Dindo classification (9). Patients were followed every 3 months for the first year, through our institutional bariatric surgery outpatient clinic. Data were entered prospectively into
the hospital’s database for bariatric patients and retrospectively reviewed. WL, BMI, and excess weight loss percent (EWL%) outcomes were evaluated at 6 and 12 months postoperatively. The study protocol was approved by the Institutional Review Board. Operative Technique and Peri-Operative Management
The surgical technique used for LAGB has been previously described (10). Basically, we used the “pars flaccida” technique and a broad, low-pressure band, the Swedish adjustable gastric band (Obtech, Baar, Switzerland, later and now associated with Ethicon Endo-Surgery, Cincinnati, Ohio, United States). LRYGB was performed using a 5-trocar, double-loop technique and treated by fast-track pathways as recently described in detail (11). Fast-track compliance was 100%. In total, 11 super-obese patients were operated by the means of circular stapler in the creation of the gastrojejunal anastomosis as also described earlier because it was our standard technique during the first 30 LRYGB cases (12). Statistical Analysis
The results of parametric and nonparametric data were expressed as mean ± standard deviation (SD), and SPSS statistical software (SPSS 16.0.1, Chicago, IL, USA) was used for all statistical analyses. Confidence intervals were set at 95%. A two-sided p value of ≤0.05 was considered as statistically significant. Comparisons between both groups were determined using Fisher’s exact test for discrete variables because of the nonparametric nature of the data and Student’s t-test for continuous variables. A post hoc statistical power of 0.184 was calculated for the two-tailed hypothesis for the continuous outcome measures, while a post hoc statistical power of 0.292 for discrete variables with an observed effect size (Cohen’s d) of 0.159. Results The two groups were comparable (Table 1). There were no significant differences in operative time (93.51 ± 33.32 vs 87.72 ± 39.24 min), conversion rates (0% in both groups), or hospital stay (2.68 ± 2.27 vs 2.75 ± 1.84). A total of six patients (5.9%) in Group 1 had intra-operative complications due to anastomotic or gastric pouch leak during intra-operative leak testing with methylene blue (three patients), bowel perforations due to stapler—iatrogenic injury—(two patients), and one case of anvil detachment from gastric tube in the upper esophagus because a circular stapling gastrojejunal anastomosis was performed that needed intra-operative gastroscopy. However, all intra-operative complications were managed without further sequel. No intra-operative complications occurred in Group 2 (0.0%), with a significant difference (p = 0.04). There were no significant differences in overall early postoperative complication rates between the groups, although the LRYGB group had a higher early morbidity rate (17.65% vs 10.12%, p = 0.20) compared to the
7
LRYGB vs LAGB in super-obese patients (BMI >50) Table 2 Postoperative complications 50)
Declaration of Conflicting Interests No commercial associations or disclosures may pose or create any conflict of interest with the information presented in this article.
References 1. Sjöström L: Review of the key results from the Swedish Obese Subjects (SOS) trial—A prospective controlled intervention study of bariatric surgery. J Intern Med 2013;273:219–234. 2. Helmiö M, Salminen P, Sintonen H et al: A 5-year prospective quality of life analysis following laparoscopic adjustable gastric banding for morbid obesity. Obes Surg 2011;21:1585–1591. 3. Sarwer DB, Wadden TA, Moore RH et al: Changes in quality of life and body image after gastric bypass surgery. Surg Obes Relat Dis 2010;6:608–614. 4. Fielding GA. Laparoscopic adjustable gastric banding for massive superobesity (>60 body mass index kg/m2). Surg Endosc 2003;17:1541–1545. 5. Buchwald H, Oien DM: Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–436. 6. Chakravarty PD, McLaughlin E, Whittaker D et al: Comparison of laparoscopic adjustable gastric banding (LAGB) with other bariatric procedures: A systematic review of the randomised controlled trials. Surgeon 2012;10:172–182. 7. Flegal KM, Kit BK, Orpana H et al: Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA 2013;309:71–82. 8. Kyrou I, Osei-Assibey G, Williams N et al: Self-reported disability in adults with severe obesity. J Obes 2011;2011:918402. 9. Dindo D, Demartines N, Clavien PA: Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240: 205–213. 10. Victorzon M, Tolonen P: Laparoscopic silicone adjustable gastric band: Initial experience in Finland. Obes Surg 2000;10: 369–371. 11. Victorzon M, Victorzon S, Peromaa-Haavisto P: Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature. Obes Surg 2013;23:1692–1967. 12. Giordano S, Tolonen P, Victorzon M: Comparison of linear versus circular stapling techniques in laparoscopic gastric bypass surgery—A pilot study. Scand J Surg 2010;99:127–131. 13. Schwartz ML, Drew RL, Chazin-Caldie M: Factors determining conversion from laparoscopic to open Roux-en-Y gastric bypass. Obes Surg 2004;14:1193–1197. 14. Victorzon M: Revisional bariatric surgery by conversion to gastric bypass or sleeve—Good short-term outcomes at higher risks. Obes Surg 2012;22:29–33. 15. Topart P, Becouarn G, Ritz P: Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Rouxen-Y gastric bypass in superobese patients. Surg Obes Relat Dis 2013;9:526–530. 16. DeMaria EJ, Schauer P, Patterson E et al: The optimal surgical management of the super-obese patient: The debate. Paper presented at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, Hollywood, FL, 13–16 April; Surg Innov 2005;12:107–121.
9
17. Christou NV, Look D, MacLean LD: Weight gain after shortand long-limb gastric bypass in patients followed for longer than 10 years. Ann Surg 2006;244:734–740. 18. Søvik TT, Taha O, Aasheim ET et al: Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Br J Surg 2010;97:160–166. 19. Suter M, Calmes JM, Paroz A et al: Results of Roux-en-Y gastric bypass in morbidly obese vs superobese patients: Similar body weight loss, correction of comorbidities, and improvement of quality of life. Arch Surg 2009;144:312–318. 20. Parikh MS, Shen R, Weiner M et al: Laparoscopic bariatric surgery in super-obese patients (BMI >50) is safe and effective: A review of 332 patients. Obes Surg 2005;15:858–863. 21. Kakarla VR, Nandipati K, Lalla M et al: Are laparoscopic bariatric procedures safe in superobese (BMI ≥50 kg/m2) patients? An NSQIP data analysis. Surg Obes Relat Dis 2011;7:452–458. 22. Favretti F, Ashton D, Busetto L et al: The gastric band: First-choice procedure for obesity surgery. World J Surg 2009;33:2039–2048. 23. Benotti P, Wood GC, Winegar DA et al: Risk factors associated with mortality after Roux-en-Y gastric bypass surgery. Ann Surg 2014;259:123–130. 24. Victorzon M, Peromaa-Haavisto P, Tolonen P: Perioperative morbidity, mortality and early outcome of the first 360 gastric bypass operations performed in a district hospital. Scand J Surg 2012;101:184–189. 25. Nguyen NT, Slone JA, Nguyen XM et al: A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: Outcomes, quality of life, and costs. Ann Surg 2009;250:631–641. 26. Angrisani L, Cutolo PP, Formisano G et al: Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 10-year results of a prospective, randomized trial. Surg Obes Relat Dis 2013;9:405–413. 27. Arapis K, Chosidow D, Lehmann M et al: Long-term results of adjustable gastric banding in a cohort of 186 super-obese patients with a BMI ≥50 kg/m2. J Visc Surg 2012;149:e143–e152. 28. O’Brien PE, MacDonald L, Anderson M et al: Long-term outcomes after bariatric surgery: Fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. Ann Surg 2013;257:87–94. 29. Werling M, Fändriks L, Björklund P et al: Long-term results of a randomized clinical trial comparing Roux-en-Y gastric bypass with vertical banded gastroplasty. Br J Surg 2013;100:222–230. 30. Neff KJ, Chuah LL, Aasheim ET et al: Beyond weight loss: Evaluating the multiple benefits of bariatric surgery after Rouxen-Y gastric bypass and adjustable gastric band. Obes Surg 2014;24:684–691. 31. Mognol P, Chosidow D, Marmuse JP: Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: A comparative study of 290 patients. Obes Surg 2005;15:76–81. 32. Bowne WB, Julliard K, Castro AE et al: Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: A prospective, comparative analysis. Arch Surg 2006;141:683–689. 33. Vidal P, Ramón JM, Goday A et al: Lack of adherence to followup visits after bariatric surgery: Reasons and outcome. Obes Surg 2014;24:179–183.
Received: April 15, 2014 Accepted: September 1, 2014
